Basic Information
| Provider Information | |||||||||
| NPI: | 1184654923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS MEDICAL CENTER OF MODESTO, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOCTORS MEDICAL CENTER OF MODESTO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 57376 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900747376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095782513 | ||||||||
| FaxNumber: | 2095763680 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095781211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERRY | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2095763790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 030000026 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30464G | 05 | CA | MEDICAID | 661516980 | 01 | AETNA US HEALTHCARE (NATI | OTHER | HSP40464H | 05 | CA | MEDICAID | 000414 | 01 | HUMANA | OTHER | HSP40464G | 05 | CA | MEDICAID | ZZZA0464Z | 01 | BS OF CALIFORNIA | OTHER | 012821-0001 | 01 | PACIFICARE OF CALIFORNIA | OTHER | HSC30464H | 05 | CA | MEDICAID |